Acute spinal cord injury

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1 Acute spinal cord injury Thakul Oearsakul Songklanagarind hospital Hat Yai Songkhla Introduction New SCI cases Approximately per population Common causes of traumatic SCI :Motor vehicle accidents 45% : fall 20% : sports 15% : violence 15% : miscellaneous 5% 1!

2 Introduction The most common site : cervical region 50-64% (incomplete:complete 2:1) : the lumbar region (conus medullaris or cauda equina) 20-24% : thoracic cord 17-19% Introduction Undiagnosed or suboptimally managed spine injury can result in a neurologic deficit and permanent impair a pts function. 2!

3 introduction Functional motor recovery 3% ( complete injury within 24 Hrs) No functional motor recovery after Hrs. Incomplete cord injury has a good prognosis Sacral sparing is important Acute care phases Diagnosis and acute management 1. Initial assessment and immobilization 2. Medical management 3. Anatomical alignment 4. Radiologic diagnosis 5. Surgical decompression 6. stabilization 3!

4 Goal of acute care phases Provide initial cardiopulmonary management, immobilization and careful transportation. Enhence blood flow to the injured SCI Prevent reinjury to the injured SCI by mechanically stabilizing the unstable Fx The first care: Initial assessment A high index of suspicion A protocol-based procedure for splinting and immobilization ATLS 4!

5 The second care: medical support Maintenance of an airway and adequate ventilation Early intubation of the pts with airway compromise In-line manual traction or awake fiberoptic intubation MANAGEMENT 0. PRE-HOSPITAL (BASIC LIFE SUPPORT, SPINAL IMMOBIILIZATION, TRANSFER) 5!

6 ! Management! How do I protect the spine? - Immobilize entire patient on long spine board with proper padding - Apply semirigid collar - Protection is priority:detection is secondary - Remove spine board as soon as possible and logroll patient - Pressure sores occur early in unconscious or paralyzed patients PRIMARY SURVEY AND RESUSCITATION! Airway and c-spine protection Breathing (above C4) Pitfall : no c-spine detection! 6!

7 Airway maintenance techniques 1. Chin-lift 2. Jaw thrust The second care: medical support! Circulation :hypovolumic shock :neurogenic shock (above T6)! Treatment :fluid resuscitation :vasopressor drug :maintain blood pressure(map>85 mmhg*5 day) :atropine! 7!

8 The second care: medical support C: FLUID RESUSCITATION AND MONITORING 1. CVP MONITORING 2. URINARY CATHETER : DURING THE PRIMARY SERVEY & RESUSCITATION : MONITOR URINE OUT PUT & PREVENT BLADDER DISTENTION 3. GASTRIC CATHETER : PREVENT GASTRIC DISTENTION AND ASPIRATION MANAGEMENT (CONT.) E; modified log roll ;hypothermia (above T8) 8!

9 MANAGEMENT (CONT.) SECONARY SURVEY spine detection Clinical Assessment NEUROLOGIC EVALUATION 1. MOTOR EVALUATION 2. SENSORY EVALUATION 3. REFLEX EVALUATION NOTE: severity and level of injury 9!

10 10!

11 CLINICAL ASSESSMENT (3) SPINAL CORD SYNDROMES * Bell s cruciate paralysis * Central cord syndrome * Anterior cord syndrome * Posterior cord syndrome * Brown-Sequard syndrome (best prognosis) * Conus medullaris syndrome Neurologic Status Neurologic level Most caudal level of motor / sensory function Motor and sensory may not be the same Sensory can vary on each side Bony level Site of vertebral column damage 11!

12 Sacral sparing! Bulbocavernosus reflex! 12!

13 Assess neurologic status (severity)! Spinal shock. ( neurogenic shock)! Complete cord Incomplete cord. (Sacral sparing)! Patient evaluation Neurological examination Spinal shock : Bulbocarvernosus reflex Sacral sparing : Perianal sensation Anal sphincter tone Motor power of toe flexor 13!

14 Assess neurologic status! motor! sensory! reflex! Spinal shock! Complete cord! Incomplete cord! -! -! -! -! -! +! +! +! +! 14!

15 Incomplete cord! 15!

16 The third care: Radiology 1. PLAIN FLIM * CROSS TABLE LATERAL CERVICAL VIEW * ANTERIOR - POSTERIOR VIEW * OPEN - MOUTH VIEW * SWIMMING VIEW * FLEXION - EXTENSION VIEW * ANTERO - POSTERIOR & LARERAL VIEW OF THORACIC, LUMBAR Magnetic Resonance Imaging (MRI)! Evaluation of spinal cord injury and soft tissue injury Persistant pain, worsening neurologic ft.! 16!

17 Adventages of MR imaging! Cause of neurological deficit :spinal cord injury :extra-axial injury (EDH,disc herniation) Presence of ligamentous injury : transverse lig. Pretraction MRI Neurological deterioration after traction and reduction. In many center,difficult to obtain within several Hrs. Rapid closed reduction is successful and safe.(sci) Waiting for MRI should not delay closed reduction(sci) Neurologically intact pt with CS dislocation : may be obtained pretraction MRI. 17!

18 Summary of clearing cervical spine! Asymptomatic: clinical exam Symptomatic: X-ray images :Neurological deficits :Obtunded :Alert, awake, Neurologically normal,but neck pain! Clinically clearing the cervical spine (asymptomatic patient)! After blunt polytrauma, the patient s cervical spine may be regarded as stable if: 1. Glasgow Coma Scale (GCS) = 15, and the patient is alert and orientated 2. No intoxicants or drugs have been consumed 3. No significant distracting injuries have occurred 4. No signs or symptoms on cervical examination: i) No midline tenderness or pain ii) Full range of active movement iii) No referable neurological deficit! The reliability and performance of these criteria requires judgement and strict application by the clinician! 18!

19 ! Guideline for Symptomatic patients! Alert, awake,neurologically normal, complaints of neck pain (ATLS (1997),EAST (2000)) :plain films and directed CT :if lower c-spine inadequate;swimmer or axial CT with reconstruction :if normal,removed collar :static F/E with pts sitting and voluntarily F/E :if F/E <30 degree,the collar should be replaced and repeat F/E in 2 wks Guideline for Symptomatic patients! Pts with neurological deficits EAST (2000) :plain films and directed CT :MRI! 19!

20 Guideline for Symptomatic patients! Altered mental status,and too young ATLS (1997) :plain films (AP,lateral,open mouth) :directed CT Not returned to normal within 2 days EAST(2000) :plain films and axial CT with saggital reconstruction occiput to C2 :directed CT :if normal,dynamic fluoroscopy F/E with static images! The fourth care: reestablish bony alignment Remove any direct mechanical compressive forces. Gardner-Wells tong or halo vest immobilization 20!

21 SPINAL IMMOBILIZATION SKULL TRACTION TONG ( GARDNER - WELLS TONG ) Adventage for : instability : realignment and stabilization Becareful :neuro exam and serial imaging when traction SKULL TRACTION TONG ( GARDNER - WELLS TONG ) Absolute contraindication * Occipitoatlantal dislocation (type II) * Concomitant open skull fractures 21!

22 22!

23 The fifth phase:surgical decompression Emergency or urgent Sx decompression Bilateral locked facets without reducing by traction (incomplete SCI) Almost all thoracic and lumbar Fx with neurological deficit require Sx decompression and/or internal stabilization (incomplete SCI) 23!

24 Surgical Goal Reduction of malalignment Decompression of the neural elements Restoration of spinal stability Timing of surgery 24!

25 Timing of surgery The sixth phase: mechanical stabilization Stability of the spinal column Prevent reinjury of the spinal cord from the unstable bony elements. Internal stabilization with hardware,external splinting 25!

26 The seventh phase : critical care Prevent stress ulcer Prevent deep venous thrombosis Effects of Spinal Cord Injury Inadequate ventilation Abdominal evaluation compromised Occult compartment syndrome 26!

27 Pharmacologic intervention Methylprednisolone! Blunt injury only Spinal cord injury Injury less then 8 hrs Start within 8 hours of injury : 30 mg/kg over 15 min : 5.4 mg/kg over next.23 hrs if started within 3 hrs of injury.48 hrs if started within 3 to 8 hrs after injury Complication : ( 48hrs) severe sepsis and pneumonia! 27!

28 Thank you! Thank you! 28!

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